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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95200 4222 (209) 46a -U20 <br />NUN-KEFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUE <br />iJOBADDRESS 1781 E Grant Line Rd CITyrzp Tracy 195304 <br />'.CROSS STREET N Chrisman Rd APN 213-070-390-000 PARCEL SZE 11.4 ACLANO USE APPLICATION <br />OWNER NAME Marie Madvn Trust PHONE <br />OWNER ADDRESS 1681 E Grant Line Road Crtr/STATPJZP Tracy / CA 195304 <br />CONTRACTOR Exploration Geoservices A PHONE (408) 280-6822 <br />CONTRACTOR ADDRESS nue �� aSt �C CrflySTATEiZP San Jose ICA /-@@++16 9s110 <br />SUBCONTRACTORICONAULTANT Cornerstone Earth Group PHONE _ (408) 2454600 <br />SUBCONTRACTOR/CONSULTANT ADDRESS 1259 Oakmead Parkway CATYISTATEIZW Sunnyvale / CA /94085 <br />LICENSE X C-57 U C-61 ❑ 0.09 Other NUMBER 484288 EXPIRATION DATE 12/31/2021 <br />Ba.LW0 PARTY: (I OWNER II CONTRACTOR X SUBCONTRACTOR/CONBULTANT <br />DouFsnc WELL SAYPLDIG: I I General MinerauColifonn Bacteria (4391) :: Dibmmochlompropane (4392) a Arsenic (4393) <br />INTENDED USF I I DomesONPrrvale a IrrlgailOn/Agriculturel I I Industrial I i Water Quality Monitoring X Soil Sampling/Charecterization <br />I I Public Wafer System <br />If GMreaf from Owner. Water symem Na" Conrad Name W PNau Number <br />TYPE OF WORK ; I New Well I I Replacement Wail U Well Alteralion/Modificat on ; : Other <br />n Monitoring Welts) .d of wells U Soil BOring(s) a of bod" sa X Geoiedmical _3 e erborloea <br />Out•01Servioe Weil C Out -Or -Service Well Renewal Cross-Connadion Repair <br />I New Pum :1 Pump Replacement U Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />DrillingMethod I I Mud Rotary Hollow Stam <br />tory ' ; Air Rotary ?(Auger I I Cable Tod I I Push Point Omer <br />Proposed Well Depth 5 to 50 fl Excavation a In diameter I Open Bottom :: Gravel Pad(/Gravel Size In diameter <br />I I Conductor Casing In diameter / Conductor Casing Depth fl <br />Well Casing Diameter _ in ThIckness/Gsuge/ASTM Schell [;SIM :: Plastic :: Slalnless Steel U Other <br />Grout Seal Depth S - crr] ft X Neat Cement (94 lb beg3-10 gel water) Sand Cement sack mixr7 gal water <br />I Benlonde(20% solids) :! Other <br />Grout Placement Method r; Pumped n Free Fall X Other Tremie Grout f) Retardant / Accelerator (name) <br />PFDFSTAL Installed By I) Driller '2 Pump Contractor !i Omer <br />I Concrete Pedestal nDlmensions: Wfdlh ft Length ft Thick to li Christy BOA I I Stove Plpe <br />leg -ME !I Submersible:; Turbine I! Other HP Pump Set ft Standing Water Level ft <br />1 HEREBYO CETY RTIFY HAVE PREPARED THIS APPUCA71ON AND THAT THE WORK WILL 13E DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND PQqE WITH YMCALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERSCOM ENS TION U&S I <br />MI M d H R A VANCE NOTICE REQUIRED F_. INSPEQTIO(NS -PLEASE CALL (209) <br />SIGNED TITLE��` �v _ DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By - /" Data %,;, AI I <br />Grout Inspection By / c -- Date, 2 r ! i 7Z i <br />Pump Inspection By Date <br />Sod Bortng Inspection By Date <br />COMMENTS <br />Mee�ii> Employee IDD <br />EI $PEC L Well Permit <br />WAIVER Received <br />Constructed Well Depth H <br />PE SC Received Checkat Amount at Pormly Invoice a Well to# <br />Codas Info Cas Remitted Service eq nest 0 <br />Er•D a}eg 6/1vMr9 YI <br />/ WELL PERMIT <br />PERM <br />pD <br />F <br />h <br />E ANT <br />ED <br />12 2021 <br />f�FN°� NTy <br />h�TfVIENT <br />